What are some of the consequences of greater communication that I should prepare for?
The implementation and Meaningful Use of EHRs create opportunities for patients and families to better manage and keep track of their health information, share information readily with healthcare providers, and make informed decision about their health. EHR technology will allow you to easily access patients’ medical records, provide care more efficiently, manage medications, reduce medication errors, and document and share information across the continuum of care. EHR technology also offers you the potential to improve communication between you and your patients, which should promote the active engagement of patients in their healthcare, and in turn foster improvements in health outcomes, care coordination, and the efficiency of practice operations for both patients and providers.
Despite these potential benefits, the transition to Meaningful Use of EHR technology and the active engagement of patients poses concerns for many healthcare providers. These concerns include the changes that will be required in workflow, the need for training staff, altered patient-clinician communications, and privacy and security issues.
Workflow is the way your practice conducts its daily business—from registering a patient at the front desk, taking height, weight and vital signs, ushering the patient into the exam room, conducting the medical exam, then ordering follow-up tests, follow-up appointments, etc. Moving from paper records to EHRs will require significant workflow adjustments of your practice and the roles of your office staff. Similarly, providing patients with copies of their medical information, clinical summaries, and health education materials will create the need for new practice patterns.
You should plan for these workflow changes prior to EHR implementation and incorporate all proposed changes into your staff training. While these new workflow patterns may initially require that tasks take more time than they did prior to EHR implementation, the new tasks and patterns will take less time and as staff becomes more familiar with their new roles. For example, at first inputting information electronically may take you more time than writing or dictating their notes, but as you become more experienced and comfortable with the EHR technology, it will take less time. Your practice should continuously assess its workflow and modify it accordingly. Many practices have found the initial EHR implementation period to be difficult, but after the office workflow adjusted, it was more efficient that it had been prior to the EHR implementation.
The Need for Training
You will need to allocate time and resources to train practitioners and support staff to use the EHR system and to incorporate the new workflow patterns. Depending on how comfortable you and your staff are with technology, you may need additional training on basic computer skills (e.g., Windows, use of a mouse, printing, creating folders, moving files) and hardware devices such as scanners, fax servers, etc. The software vendors generally provide training on their EHR product. You should discuss the workflow processes of the practice with the vendor/trainer ahead of time so that the trainer can offer relevant tips to help your staff optimize their use of the EHR system and minimize disruptions to workflow. Practices can also consider allocating “super users” or using the “Train the Trainer” approach, where few employees and staff are trained to serve as experts who assist, support and train the staff after the EHR system goes live. After rules for Stages 2 and 3 of Meaningful Use are announced, additional training will be needed to inform providers of the new rules and how to use the new EHR functions.
Although EHR technology is expected to improve information sharing, it is less clear how its actual use will affect interpersonal communication and the provider-patient relationship. Many providers are concerned that using a computer with a patient in an examination room will hinder communications (e.g., reduced eye contact, conversation, and emotional contact). While EHRs do alter the communications, there is no evidence that interpersonal communications are negatively affected. In fact, surveys of Kaiser Permanente patients found no negative effect of the use of computers during exams.
To overcome these communication challenges, you should integrate EHRs into medical practice in such a way that supports rather than hinders interpersonal communication. Kaiser Permanente physicians have many years of experience using EHRs and have identified five key communication behaviors (LEVEL) to foster smooth integration of computers into practice:
Let the patient look on
Eye contact with the patient
Value the computer as a tool
Explain what you are doing
Log off and say you are doing so
Kaiser Permanente has found that physicians’ discomfort with EHR usage fades as confidence is gained in new skills, in a sense of consistency and reliability about critical patient data, and in satisfaction with the comprehensive level of care that the clinicians are able to provide. In fact, ample evidence exists that shows that computing can enhance the overall clinician-patient interaction in the exam room.
Privacy and Security Issues
One of the major concerns voiced by health care providers about adopting an EHR system are the privacy and security issues related to patient privacy, confidentiality and security of EHRs. Providers fear confidentiality breaches, risk of hacking, losing of records, inappropriate access of patient records by unauthorized users, and maintaining compliance with Health Insurance Portability and Accountability Act (HIPAA) privacy and security regulations. Providers understand that if patients or other providers lack trust in their EHR system due to perceived or actual risks to their health information or the accuracy and completeness of such information, it may affect their willingness to disclose necessary health information.
Your certified EHR technology will allow you to comply with all necessary HIPAA and HITECH regulations. You will need to ensure, however, that you and your office staff understand HIPAA requirements and fulfill your responsibility to protect personal health information (PHI). PHI refers to individually identifiable health information. Individually identifiable health information is that which can be linked to a particular person. Specifically, this information can relate to:
Common identifiers of health information include names, social security numbers, addresses, and birth dates. The HIPAA Security Rule applies to individual identifiable health information in electronic form or electronic protected health information (ePHI). It is intended to protect the confidentiality, integrity, and availability of ePHI when it is stored, maintained, or transmitted.
How to Successfully Navigate Your EHR Implementation – American Academy of Family Physicians’ article provides helpful suggestions for implementing EHR systems.
Health IT System Implementation – HRSA Health IT Adoption Toolbox module covers a broad spectrum of implementation activities, from a detailed workflow analysis to the formal go-live of the new system.
Organizational Change Management – HRSA Health IT Adoption Toolbox module on EHR change management and training.
Computers in the Exam Room: Friend or Foe? – Kaiser Permanente journal article discussing EHR implementation and providers experience with EHR usage in the exam room.
Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less? – Center for Studying Health System Change issue brief details clinician perception of the electronic medical records use and communication challenges and solutions.
Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation – Article examines effects of EHR implementation in patients-physicians communication and behaviors.
Doctors need more eye contact with patients, not computers – Article discusses the patient–clinician communication and the importance of eye contact.
Patient-centered Care and Electronic Health Records: It’s Still About the Relationship – Article elaborates on the importance of integration of patient centered care with EHR system use.
Maximizing the Value of Meaningful Use Investments: Achieving the Patient‐Centered Care Objective through Interactive Communication Systems – Paper examines the Meaningful Use requirements, with a focus on the use of interactive communication tools to advance patient‐centered care objectives.
ONC Privacy and Security – ONC’s webpage for EHR and health information exchange information.
Understanding HIPAA Privacy – Information on HIPAA Privacy Rule for Consumers and Covered Entities.
Health Information Technology and HIPAA – Guidance documents on the application of the Privacy Rule in the electronic exchange of health information.
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